Microvascular reconstruction of soft tissue defects in the head and neck.

The ability to bring distant well vascularized tissue to the head and neck has created new reconstructive options following surgical ablation for malignancy. Although the initial operative time is increased, microvascular free tissue transfer reconstruction often yields a superior result without the need for multiple staged operations. A multitude of donor sites have been developed, each with an advantage for reconstruction. Free tissue transfers are especially indicated when local tissue is deficient, of a poor quality or where a highly vascular flap is needed.

The effect of fibrin glue on skin grafts in infected sites.

Fibrin bonding of skin grafts to wounds is an essential part of the graft-adherence process. Bacteria, in concentrations greater than 10(5)/gm of tissue, are associated with graft failure. Sixty-five rats were randomly divided into three groups, dorsal split-thickness skin grafts were harvested, and the sites were inoculated with Staphylococcus aureus. After incubation, each wound was quantitatively biopsied and treated with saline, fibrin glue with aprotinin, or fibrin glue alone. We found that the addition of commercially available fibrin glue with or without the antifibrinolytic agent aprotinin is capable of restoring graft adherence to normal levels in graft sites infected with greater than 10(5) bacteria/gm of tissue. Fibrin glue may have potential for increasing skin-graft take in the clinical situation where the graft bed is infected.

Perforation of the hard palate associated with cocaine abuse.

Cocaine abuse is associated with serious systemic complications. Snorting cocaine can also cause complications of the nasopharyngeal structures. Repeated episodes of vasoconstriction and subsequent ischemia may cause this destruction. We present a patient with perforation of the nasal septum and palate and collapse of the nasal dorsum. The destroyed anatomy was reconstructed by using standard surgical techniques. Palatal destruction is a rare entity and, to our knowledge, this patient is the first reported patient with palatal destruction due to cocaine insufflation.

Clinical experience with immediate breast reconstruction using tissue expansion or transverse rectus abdominis musculocutaneous flaps.

We retrospectively reviewed our experience with immediate breast reconstruction in 103 consecutive patients with stage 0 or I breast carcinoma between May 1983 and April 1988. Two reconstructive techniques were used, that is, either tissue expansion with secondary prosthesis implantation (60%) or transverse rectus abdominis musculocutaneous (TRAM) flap (40%). Chemotherapy was administered in 22% of patients without delay or compromise. The mean length of follow-up is 30 months. The complication rate was equal for both groups (24%) with infection being most common in the group of patients with tissue expansion and partial flap necrosis being most common in the group of patients with TRAM flaps. Aesthetic results were superior with use of the TRAM flap. Our experience concurs with previous reports that documented satisfactory results with immediate breast reconstruction without compromising further therapy. We conclude that although the tissue expansion technique yields acceptable results, the TRAM flap yields superior aesthetic results in terms of both appearance and consistency.

Mammary hypertrophy is not associated with increased estrogen receptors.

Estrogen promotes secondary female sex characteristics, including breast enlargement. Since excessive breast hypertrophy is unrelated to elevated serum estrogen levels, it has been postulated that the enlarged breast is a hypersensitive "target organ." At the cellular level, estrogen crosses the cell membrane, is bound to a cytoplasmic estrogen receptor (ER), and induces the formation of specific anabolic proteins. In breast cancer, this estrogen receptor is regarded as a measure of the sensitivity of the cell to estrogen. To determine if mammary hypertrophy is related to an increase in the number of estrogen receptors, we assayed breast tissue, not fat, from 25 consecutive breast reductions. The median age of patients was 26 years (17 to 77 years), with 752 gm per breast removed on average. Twenty-four percent of the patients were taking estrogens, primarily birth control bills. Cellular estrogen-receptor status was measured by a standardized cytosol extraction radioactive estradiol technique. Estrogen receptors were undetectable (less than 3 fmol/mg cytosol protein) in all patients. We conclude that estrogen receptors alone, and hence estrogen, are not a determinant in mammary hypertrophy. If the enlarged breast is a "target organ," it is by another mechanism.

The application of antibody coated polyacrylamide gel (immunobead) in the NBT test for the detection of ingestion and killing functions of human neutrophils.

An improved assay for the simultaneous assessment of phagocytic uptake (via immunobeads) and metabolic integrity (via NBT dye reduction) in neutrophils is described. Normal human neutrophils exhibited ingestion and dye reduction, whereas neutrophils from newborn cord blood showed ingestion with slight reduction and neutrophils from patients with chronic granulomatous disease displayed hyper-ingestion and no subsequent dye reduction.